Confirming Insurance Benefits

Health insurance plans are notoriously difficult to navigate. Benefits can be very complex, which leaves many people unsure of their coverage details. Because of this, it is very smart to get into the habit of proactively researching and confirming benefits before receiving planned medical care. In this article, we will be taking you through best practices in understanding and confirming your benefits. 

Summary of Benefits and Coverage

Under the Affordable Care Act, all insurance companies are required to provide a “Summary of Benefits and Coverage” (SBC) document. A plan’s SBC is intended to help individuals understand a plan’s coverage. This summary helps to clarify the broad costs and structure of the insurance plan, without getting into the technical details. This can help you compare plans during open enrollment, and also to understand coverage when planning for medical care. 

The Summary of Benefits and Coverage will take you through several patient-examples, outlining sample procedures and the associated patient cost. When you are trying to understand the costs and coverage for medical care, the SBC will be the best place to start.

Coverage Agreement 

While the SBC provides a broad overview of coverage, the plan’s Coverage Agreement (or benefits booklet) goes into much more detail. It will outline coverage for many different types of medical care. While the document will have a glossary, we recommend opening the PDF on your computer and searching the keywords you’re looking for. For example, if you want to understand your plan’s physical therapy coverage you can search “physical therapy,” “physical therapist,” and “PT” until you find the section that details coverage, restrictions, and protocols for this type of care.

Confirming Coverage

If you or your loved one are undergoing an especially involved procedure, it can be a great idea to triple-confirm your insurance coverage before you receive medical care. After reading your Summary of Benefits and Coverage Agreement, we suggest:

  • Make sure the healthcare provider has done “insurance verification” with the health insurance company. This is the process by which they contact the insurance company to confirm: benefits and patient costs, that they’re an in-network provider, and that the specific procedure will be covered. 
  • Call the insurance company yourself to confirm. First, ask the healthcare provider what “insurance codes” they will be using for the procedure. Then, call the insurance company and make sure these codes are covered by the plan. Note down the date, name of person you spoke with, the call reference number, and any details they share about the coverage. This will be incredibly useful to have on hand if there is a coverage dispute at a later date.

Though this can be a lot of work – especially when you or your care-recipient are experiencing medical issues – taking the time to confirm benefits can save a lot of headache and money down the line. 

Explanation of Benefits

After receiving medical care, the health insurance provider might sendan Explanation of Benefits. An EOB describes what costs the insurance provider will cover for the medical care received, and what the patient responsibility will be. 

The EOB is intended to clarify:

  • The total cost of the medical care received 
  • What portion of the cost the insurance provider will be covering
  • What out-of-pocket costs will be 

Importantly, an EOB is not a bill. Rather, it is a statement that details the services received and how the patient and insurance provider will share costs. The bill will come separately from the provider. 

After receiving an EOB, it is important to check it for accuracy. Sometimes errors can appear that will impact insurance coverage. Check the EOB to make sure:

  • The personal information of the person who received medical services is correct 
  • The bill only covers services that were actually received 
  • The patient is not being double billed for the same service twice 
  • Understand what the insurance company is paying, and that it is in line with the coverage outlined in the Summary of Benefits

If there is anything that is inaccurate or you’d like to clarify, call: 

  • The insurance company. The patient services phone number should be listed on the insurance card. 
  • The healthcare provider. If there are mistakes on the EOB, they will be able to correct this with the insurance provider. 

Negotiating Healthcare Bills

Ideally, we would all understand the costs before undergoing medical care. However, that is not always possible – unplanned procedures are a reality, especially as we age or develop chronic conditions. Sometimes despite our best efforts, we will receive unexpected medical bills that we can’t afford. In these situations, you’ll need to speak with your provider and see what agreement you can come to. Check out our post on how to negotiate healthcare bills

Next Steps 

If understanding healthcare coverage feels overwhelming, you are not alone! The American healthcare system is incredibly complex, and people are routinely left with unexpected bills that are difficult to understand and afford. At Aidaly, we’re here to help you with this. Please let us know what else you'd like us to cover to help simplify this process.

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